IDSP 14 :medicos11.com

IDSP 14www.medicos11.com : IDSP 14www.medicos11.com

Surveillance of the risk factors for non-communicable diseases (NCDs) : Surveillance of the risk factors for non-communicable diseases (NCDs) IDSP training module for state and district surveillance officers Module 14

Learning objectives (1/2) : Learning objectives (1/2) Describe the importance and the need for surveillance of risk factors for non communicable diseases Enumerate the differences between surveillance for communicable diseases and risk factors for non communicable diseases List non communicable disease risk factors under surveillance

Learning objectives (1/2) : Learning objectives (1/2) List steps involved in organization and conduct of surveillance of risk factors for non communicable diseases Describe the role of the district surveillance officer in surveillance of risk factors for non communicable diseases

Communicable versus non-communicable diseases : Communicable versus non-communicable diseases Communicable diseases Sudden onset Single cause Short natural history Short treatment schedule Cure is achieved Single discipline Short follow up Back to normalcy Non-communicable diseases Gradual onset Multiple causes Long natural history Prolonged treatment Care predominates Multidisciplinary Prolonged follow up Quality of life after treatment

Projected proportional increase in population > 65 years age, 2000-2030 : Social Determinants of Health Inequalities, Marmot M, Lancet 2005 Projected proportional increase in population > 65 years age, 2000-2030 0% 50% 100% 150% 200% 250% Mexico Chile India China USA UK Japan Italy Proportion (%)

Projected population pyramid of India : Projected population pyramid of India

Estimated and projected proportion of deaths due to non-communicable diseases, India, 1990-2010 : Estimated and projected proportion of deaths due to non-communicable diseases, India, 1990-2010 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1990 2000 2010 Year Proportion (%) Injuries Communicable diseases Non communicable diseases

Estimated and projected specific mortality rate per 100,000, by sex, India : Source : World Bank Health Sectorial Priorities Review Estimated and projected specific mortality rate per 100,000, by sex, India Epidemiological transition: The concept of evolution from a communicable diseases burden of disease profile to a predominance of non communicable disease

Burden of major non-communicable diseases, India, 2004 : Ischemic heart diseases Stroke Diabetes Burden of major non-communicable diseases, India, 2004

Non communicable disease programmes in India : Non communicable disease programmes in India National cancer control programme National mental health programme National blindness control programme Cardiovascular diseases, stroke and diabetes programme Trauma and accident programme Oral health programme Rehabilitation programme Geriatric care programme

Existing reporting systems for non communicable diseases in India : Existing reporting systems for non communicable diseases in India Sentinel surveillance systems National Cancer Registry Programme Periodic surveys/studies Census of India Sample registration systems National sample surveys National family health survey National nutrition monitoring programme

Sources of data collection for non communicable diseases in India : Sources of data collection for non communicable diseases in India Mortality data Medical certificates for death Cause of death surveys Hospital records Morbidity data Registry (Cancer) Special surveys Hospital reports Risk factors Special surveys Registries Cancer (Shift from hospital to community based) RF/RHD (Jai Vigyan Mission) Thalasemia (Jai Vigyan Mission)

Implementation of non communicable diseases programmes in countries of the WHO South East Asia region : Source:Non-Communicable Diseases in South-East Asia Region, A Profile, WHO, 2002 Implementation of non communicable diseases programmes in countries of the WHO South East Asia region

Prioritizing surveillance for non communicable diseases : Prioritizing surveillance for non communicable diseases Mortality? Morbidity? Disability? Risk factors The risk factors of today are the diseases of tomorrow

Life course approach for the prevention of non communicable diseases : Age Development of non communicable diseases Foetallife Adult Life Adolescence Infancy andchildhood SES Nutrition Diseases Linear growth Obesity Obesity Lack of activity Diet Alcohol, Smoking SE potential Established adult risk factors (behavioural/biological) SES Maternal nutritional status & obesity, Fetal growth Accumulated risk Range of individual risk Accumulated risk Life course approach for the prevention of non communicable diseases

The causal chain explains the risk factor approach for surveillance of non communicable diseases : Disease outcomes Heart disease Stroke Diabetes Cancer Respiratory diseases Physiological risk factors Body mass index Blood pressure Blood glucose Cholesterol Behavioral risk factors Tobacco Alcohol Physical inactivity Nutrition The causal chain explains the risk factor approach for surveillance of non communicable diseases

Rationale of the risk factor approach for non communicable diseases : Rationale of the risk factor approach for non communicable diseases Non communicable diseases are slowly evolving Early recognition difficult A number of risk factors influence one or more non communicable diseases Risk factors have the greatest impact on non communicable diseases mortality and morbidity Effective modification of risk factors is possible through primary prevention Projections may be used to estimate burden Simple surveillance systems can be used Measurements standardized and validated and obtainable within ethical limits

The WHO STEPwise approach to surveillance of non-communicable disease risk factors : Step 3(Biological) Comprehensiveness Complexity Step 2(Physical) Step 1(Verbal) Core Expanded Optional At each step The WHO STEPwise approach to surveillance of non-communicable disease risk factors Sequential approach, step by step

Heterogeneity of non-communicable risk factors in India : Kerala Delhi Jammu & Kashmir Nagaland Bihar High literacy rate, developed Metropolitan city, highly urbanized, heterogeneous population Nested population Terrain, relatively underdeveloped Nested population Underdeveloped, Tribes and Terrain Illiterate, Poor population Rural, Agricultural, Tribals Different dietary patterns Different body composition Different habits Heterogeneity of non-communicable risk factors in India

Risk factors under surveillance : Risk factors under surveillance Tobacco use Alcohol consumption Raised blood pressure Systolic and diastolic Obesity Height, weight, body mass index, waist circumference Diet Low fruit, high fat, added salt to served food Physical inactivity Diabetes mellitus Fasting plasma glucose High serum cholesterol

How surveillance for non-communicable diseases differs : How surveillance for non-communicable diseases differs Surveillance methods: Estimating the prevalence of risk factors Periodic sample surveys in each state every five years Data generated: Prevalence of risk factors and unhealthy life style Time trends Geographical distribution Distribution among various populations

Type and frequency of surveys : Type and frequency of surveys Periodic sample surveys conducted in states once in five years 20% of districts surveyed each year Whole population covered in 5 years Survey conducted every year in randomly selected districts in a five-year cycle

Organization of the surveys : Organization of the surveys Practical implementation Institution with sufficient epidemiological capacity Best bidders Coordination and supervision State directorate of public health State surveillance unit District surveillance unit

Target population for survey : Target population for survey Population of 15 years to 64 years. 10-year age groups 15-24 25-34 35-44 45-54 55-64 Sampling technique National Family Health Survey Cluster sample survey

Sample size : Sample size 2500 persons across the 15-64 years age range 250 participants in each 10-years age group Two strata 2500 individuals in urban area 2500 individuals from rural area

Proposed survey design : Proposed survey design Primary sampling unit Village in case of rural area Ward (Census Enumeration Block) in case of urban area Stratification of primary sampling units based on selected variables House-listing in primary sampling units Within each selected household, all male and female members aged between 15-64 years are surveyed

Survey instrument : Survey instrument A pre-tested simple questionnaire Developed on the basis of the WHO (STEPS) Modified for the Indian context Already in use for sentinel surveillance for cardiovascular risk factors in 10 selected industrial populations all over India

Information collection : Information collection Questionnaire Measurement Height Weight Blood pressure Biochemical results Fasting blood glucose Serum cholesterol

Step 1: Individual questionnaire (1/2) : Step 1: Individual questionnaire (1/2) Baseline demography Identification, age, sex, education, occupation Alcohol consumption Current drinkers, frequency, quantity Tobacco (Smoking and smokeless) Age at initiation, usage, cessation

Step 1: Individual questionnaire (2/2) : Step 1: Individual questionnaire (2/2) Diet, fruits and vegetables In a typical week, frequency and quantity Physical activity At work, transportation and leisure History of diagnosis and treatment Hypertension and diabetes

Data collection instrument and analysis : Data collection instrument and analysis Computer friendly data collection instrument Easy data entry Automated data analysis through programme Generation of information on trends and patterns of non communicable disease risk factors

Findings and their uses : Findings and their uses Information generated on non communicable disease risk factors: Trends Prevalence in various areas Distribution in the populations Uses: Document the need for prevention and control programmes in the community Influence policy makers Guide financial allocation

Ensuring validity : Ensuring validity Maximize response fraction Use valid and reliable instruments Calibrate instruments Train staff Ensure participation of individuals selected Reduces the probability that those who do attend are unrepresentative of the sample Engage district surveillance officer and other health personnel Use existing local public health infrastructure

Role of the district public health laboratories : Role of the district public health laboratories Conduct tests: Blood sugar Cholesterol Co-ordinate collection, transport and receipt of the samples from the periphery Plan capacity to carry out analyses quickly Ensure quality control of biochemical assays Key factor to ensure useful results

Quality assurance : Quality assurance Common protocol Standardized training Standardized survey methods Monitoring and coordinating set ups Advisory group and resources Site visits Common data management mechanisms Critical appraisal

Ethical considerations : Ethical considerations Questionnaires dealing with lifestyle issues and simple non-invasive measurements Verbal consent Blood pressure Need to clarify whether persons with elevated readings would be followed up and treatment provided Written consent needed Collection of blood Requires prior ethical clearance Built-in plans for treatment of those with raised levels Built-in consent form in the questionnaire

Promise to care : Promise to care Referral, diagnostic and treatment support to persons identified with non communicable disease risk factor will be built into the system Patients identified with hypertension, diabetes will be referred to the next level for treatment

Timing of the survey : Timing of the survey Physiological and cultural considerations Overnight fasting needed Start early in the morning (6:00 am) Finish early in the afternoon (1:00 pm) Rest of the day Coding forms Dealing with the laboratory specimens and other documentation Preparations for the next day

Follow up action : Follow up action Coordinated approach for community level interventions Partnerships Medical colleges, state health departments, primary health care services and non-governmental organisations Dissemination of health education material on causes, prevention and incentives to enhance public awareness

High risk and population approaches to prevention : Truncate high risk end of exposure distribution (e.g., organize an obesity clinic). Clinical approach to disease prevention Reduce a small amount of risk in a large number of people (e.g., reduce fat a little in fast-food outlets). Lifestyle change plus environmental approach High risk and population approaches to prevention More burden from a large proportion of the population exposed to moderate risk factors than from a small segment exposed to a high risk factor

Intervention strategies : Intervention strategies Population based strategy Prevent non-communicable diseases in the whole population High-risk strategy Target people with identified risk factors

Slide 43 : Public health interventions Policy interventions Educational interventions Health beliefs and behaviours (Community; Individual) Desired change Enabling environment (Financial, Social, Physical)

Challenges and opportunities : Challenges Huge population Many programmes Rural population Emerging epidemics Unemployed youth Burden of non communicable diseases Opportunity Good sample size Different strategies Complex exposures Interventions Trained workforce Feasible intervention Challenges and opportunities

Points to remember (1/3) : Points to remember (1/3) The burden of diseases due to non communicable diseases in India became almost equal to that due to communicable diseases in 1990 The burden of non communicable diseases is increasing while it is declining in developed countries because of surveillance and interventions The life style related modifiable risk factors for non communicable diseases have been identified and the magnitude of their impact is documented

Points to remember (2/3) : Points to remember (2/3) The major non communicable diseases share common, preventable life style risk factors There is sound evidence that non communicable diseases can be reduced through a package of simple, effective and feasible life style changes The treatment of non communicable diseases is expensive and therefore the key to control is in its primary prevention

Points to remember (3/3) : Points to remember (3/3) Non communicable diseases surveillance is therefore considered an important component of the integrated disease surveillance project Non communicable diseases surveillance will be done by periodic surveys of selected risk factors and will be independent of regular surveillance for other conditions The Non communicable disease risk factors to be measured in include: tobacco use, alcohol consumption, high blood pressure, obesity, diet, physical inactivity, fasting plasma glucose and serum cholesterol

Additional slides : Additional slides (Methodology)

Urban sampling : Urban sampling

Stratification for sampling in urban areas : Stratification for sampling in urban areas

Clusters in urban sampling : Clusters in urban sampling

Choosing the city or the town : Choosing the city or the town Choose the city by simple random sampling method Choose towns by probability proportional to size and then by random sampling method

Choosing household clusters : Choosing household clusters Obtain map areas of the town /city Divide city or town into zones by ethnicity, caste/ religion and income grade Cluster allotted as per share in population where as taking into consideration above divisions

Choosing household in cluster : Choosing household in cluster Map the area specific to households Number households Obtain population and demographic data pertaining to households Select households by random sampling on the list and mark them on the map

Design of the sample in rural areas : Design of the sample in rural areas

Number of villages : Number of villages

Sampling frame : Sampling frame

Selecting the village : Selecting the village Divide the district into 2 / 3 geographical zones Decide the number of villages in each zone as per the proportion of rural population Make a list of all the villages in the zone with maps Choose the number of villages needed using random numbers among the list from each zone

Selecting the house cluster : Selecting the house cluster Make a list of households, also a map with numbers depicted. Choose from the list by random numbers the exact households. No substitution allowed. Repeat survey once / twice to cover the temporarily uninhabited households.